Martin Marshall: GPs need to do less, but it’s not what patients want to hear | Denis Campbell

The NHS does too much medicine”. These are surprising words to hear uttered by a GP, given their role as gatekeepers to the NHS – the doctors who send patients to hospital for tests, surgery or other treatment.

But Martin Marshall, the new chair of the Royal College of General Practitioners, firmly believes that part of the reason the NHS is so overstretched is that doctors (GPs and hospital doctors) overdiagnose illness – and as a result patients have too many exploratory tests and too many unnecessary treatments. Getting a grip on that, he believes, would help relieve the pressure on the health service in general and the nation’s overworked family doctors in particular.

Marshall, 58, has just begun a three-year stint as the profession’s leader and main mouthpiece, replacing Helen Stokes-Lampard. He believes “medicine has overstretched itself” and its limits need to be “rethought”, to be scaled back.

So how does overdiagnosis and overtreatment manifest itself? Marshall says that a good example is the way that statins and antibiotics are overused to treat ailments that could be just as well tackled in some other way – or which need no pharmacological or medical intervention at all.

“We’re kind of sheep-dipping the population in statins, with a relatively small benefit,” he says of the cholesterol-lowering drugs currently used by many millions of Britons. “Statins are over-prescribed. That’s what we believe as GPs, though there are quite a lot of cardiologists out there who don’t believe that. That’s where the ethical discussion comes in about whether to intervene or not.”

He believes that while statins reduce the risk of a heart attack or stroke for some, for many the potential side effects – muscle pain, diarrhoea and headaches – outweigh that.

Marshall is a professor of healthcare improvement at University College London as well as a GP in Newham, in the East End. He cites the British Medical Journal’s Too Much Medicine campaign, and similar initiatives in the US and Italy, to show that other medics share his concerns. He is also co-chair of NHS England’s expert advisory committee on the evidence-based interventions programme (EBI), which is encouraging doctors and clinical commissioning groups to reduce, or end, their use of treatments that the evidence suggests do not work – or do not work well enough to warrant the use of expensive and increasingly precious NHS resources such as staff, equipment and operating theatre time.

He cites exploratory operations for knee pain called arthroscopies, removal of nodules that indicate thyroid cancer and treatment for prostate cancer as procedures that could be done much less often, and the patient’s condition managed in some other way, including “watchful waiting”.

But he acknowledges that there are two main obstacles to embedding this “less is more” approach across the NHS: resistance from fellow doctors – and resistance, especially, from patients. With medics, especially those in hospitals, their instinct, their habit and their training tell them to intervene. In the case of knee pain, this might mean undertaking surgery when advising someone to take regular exercise rather than have an arthroscopy may well be better for them. To many doctors, though, it seems counterintuitive, he says.

Doctor writing a prescription

‘With GPs under so much time pressure, some will take the quick and easy way out and dash off a prescription.’ Photograph: Anthony Devlin/PA

Pressure from patients is key, too: Marshall admits that they often just want something done. So if a GP is having a typically busy day of umpteen consultations, “the temptation to take the easy way out, to do the quicker thing, even if it’s using unnecessary resources or exposing people to unnecessary radiation, is always there … I feel passionately about this, but it’s very tricky to persuade doctors to do less and patients to expect less,” he observes.

Ideally, he adds, a GP would take 10 to 15 minutes to persuade a patient that they do not need to start on statins. But, he says, with GPs under so much time pressure, some will take the quick and easy way out and dash off a prescription for the drugs instead.

The state of general practice has become a key issue in the election campaign. Marshall insists that he is a “glass half-full” optimist on the many problems facing this bedrock of NHS care. “[In recent years] general practice has been through a massive crisis. But I think it has hit the bottom and is now on the way up,” he says. NHS policymakers and ministers have realised how fragile GP services have become, he says.

He mentions the extra £4.5bn earmarked for community healthcare services by 2023-24 under NHS England’s long-term plan, the record number of future GPs now in training and the drive to expand GP surgeries’ workforces by adding 20,000 pharmacists, physiotherapists and mental health therapists as evidence that things are changing.

All three of the main parties have vowed to increase the number of GPs in England, even though the total has actually fallen since the government’s pledge to do so in 2015. Wisely, Marshall is sceptical.

“It’s good to see all major political parties making promises about the NHS, particularly general practice, in their manifestos. These pledges are necessary – but delivering them will be a huge challenge. We’re never going to get enough doctors into the system. It’s essential we get those 20,000 extra practice staff. Do I think we will? I’m hopeful – not confident.”

He also wants parties to think much harder about how to stop the brain drain of GPs retiring early because they feel the job has become “undoable”.

“A lot of my peer group are either retiring or working part-time or giving up their partnerships. When I started as a GP 30 years ago, a busy day was seeing 20-25 patients face to face, taking five phone calls and making three or four home visits. Now a busy day is seeing 40-50 patients, probably 20 or 30 phone calls and very few visits.” He worries that too much of what should be a very personal service has become “transactional”.

Looking ahead to the election, he adds: “Whatever party comes to power will need to be on their A-game and take serious steps to achieve their pledges. What’s missing from all the manifestos is detail, particularly about how we’re going to retain our existing workforce. Escalating workload means being a GP can be undoable. Experienced GPs are burning out and leaving earlier in their careers than they planned. That’s not right and it’s not safe – it’s something the future government needs to tackle as a priority.”


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